| NPI | 1962772541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: NY 291387) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101254407) |
| 171000000X Military Health Care Provider (Licence: NY 291387) | |
| 208000000X Pediatrics (Licence: VA 0101254407) | |
| Enumeration Date | 2012-01-12 |
| Last Update Date | 2018-03-17 |